Camp Evelyn Summer 2012 Health Form, Girl Scouts Of Manitou Counci
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1
2Health History Form:
Required for all campers attending Camp Evelyn
Please type or write clearly and legibly.
Name(Last, First, Middle Initial):
Date of Birth:
Age:
Home Address:
City:
St:
Zip:
Parent/Guardian:
Phone:
Alt. Phone:
Emergency Contact Information:
In case of an emergency, notify (parent/guardian will be contacted first, please provide additional person)
Emergency Contact:
Relationship:
Phone:
Health Insurance Information
Bills for medical visits will be mailed to home address above unless box checked, complete insurance information is
supplied, and insurance card is provided:
Bill me at home address
Insurance card and all information attached
Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include
allergies to medications, food, bees, animals, plants, etc.
Allergies
Reaction/ Severity
Treatment
Date of last Reaction
1.
2.
3.
Does your camper suffer from Anaphylaxis?
Yes
No
Does your camper carry an Epipen?
Yes
No
Does your camper carry an inhaler?
Yes
No
*Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing.
Medical Conditions (including any precautions or restrictions on activities)
Name of Condition
Effects
1.
2.
Medications: List any medications currently taken, including dosage schedule and specific instructions for use.
Time(s) to be given
Medication
Purpose
Dosage
Please Circle
1.
AM NOON DINNER BEDTIME AS NEEDED
2.
AM NOON DINNER BEDTIME AS NEEDED
3.
AM NOON DINNER BEDTIME AS NEEDED
Over-the-Counter Medications: The following will be on hand in case your camper experiences minor health
discomfort during her stay.
•
Tylenol/Acetaminophen
•
Sudafed/Decongestant
•
Cough Drops or Throat
Lozenges
•
Aspirin (fever reducer)
•
Pepto Bismol
•
Skin Ointments or Sprays
•
Ibuprofen (pain/swelling)
•
Tums/Antacid
(Anti-Itch, Neosporin,
•
Benadryl/Antihistamine
•
Laxatives (constipation)
Calamine Lotion)
•
Robitussin/Expectorant
•
Imodium (anti-diarrhea)
Please list those medications you will not permit the camp staff to administer to your camper and/or special considerations
regarding over-the-counter medications.
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Does your camper have a Special Medical or Dietary Regiment to be followed?
Yes
No
If so, please explain:
____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
*Complete the authorization found on page 16 and submit with your camper’s registration in addition to the Health History Form.
Camp Evelyn Summer 2012
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